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Biomedical subjects

H J Sugerman

Publications and source records attributed to H J Sugerman.

At least 37 records · Page 2Linked to original sources
PubMed2000

Laparoscopic closure of mesenteric defects after Roux-en-Y gastric bypass.

Two case reports are presented of incarcerated small-bowel internal hernias through mesenteric defects following Roux-en-Y gastric bypass surgery (one case each of open and laparoscopic). Both patients first presented to physicians unfamiliar with bariatric surgery complaining of vague, cramping midabdominal pain, and the correct diagnosis was not revealed until laparoscopic surgery was performed. Treatment then resulted in quick recoveries. This type of hernia can evade radiologic testing. Prompt clinical recognition and treatment is necessary to prevent small-bowel infarction.

Adult↗
PubMed2000

Ileal pouch anal anastomosis without ileal diversion.

OBJECTIVE: To evaluate continued experience with a one-stage stapled ileoanal pouch procedure without temporary ileostomy diversion. SUMMARY BACKGROUND DATA: Most centers perform colectomy, proctectomy, and ileal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedures for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the need for temporary ileal diversion, with its complications and need for subsequent surgical closure. METHODS: Two hundred one patients underwent a stapled IPAA since May 1989, 192 as a one-stage procedure without ileostomy, and 1 with a concurrent Whipple procedure for duodenal adenocarcinoma. Patient charts were reviewed or patients were contacted by phone to evaluate their clinical status at least 1 year after their surgery. RESULTS: Among the patients who underwent the one-stage procedure, 178 had ulcerative colitis (38 fulminant), 5 had Crohn's disease (diagnosed after IPAA), 1 had indeterminate colitis, and 8 had familial adenomatous polyposis. The mean age was 38 +/- 7 (range 7--70) years; there were 98 male patients and 94 female patients. The average amount of diseased tissue between the dentate line and the anastomosis was 0.9 +/- 0.1 cm, with 35% of the anastomoses at the dentate line. With 89% follow-up at 1 year or more (mean 5.1 +/- 2.4 years) after surgery, the average 24-hour stool frequency was 7.1 +/- 3.3, of which 0.9 +/- 1.4 were at night. Daytime stool control was 95% and night-time control was 90%. Only 2.3% needed to wear a perineal pad. Average length of hospital stay was 10 +/- 0.3 days, with 1.5 +/- 0.5 days readmission for complications. Abscesses or enteric leaks occurred in 23 patients; IPAA function was excellent in 19 of these patients (2 have permanent ileostomies). In patients taking steroids, there was no significant difference in leak rate with duration of use (29 +/- 8 with vs. 22 +/- 2 months without leak) or dose (32 +/- 13 mg with vs. 35 +/- 3 mg without leak). Two (1%) patients died (myocardial infarction, mesenteric infarction). CONCLUSIONS: The triple-stapled IPAA without temporary ileal diversion has a relatively low complication rate and a low rate of small bowel obstruction, provides excellent fecal control, permits an early return to a functional life, and can be performed in morbidly obese and older patients.

Adenomatous Polyposis Coli↗
PubMed2000

Effects of increased renal parenchymal pressure on renal function.

OBJECTIVE: Acute renal failure is seen with the acute abdominal compartment syndrome (AACS). The cause of acute renal failure in AACS is thought to be multifactorial, including increased renal venous pressure, renal parenchymal pressure (RPP), and decreased cardiac output. Previous studies have established the role of renal venous pressure as an important mediator of this renal derangement. In this study, we evaluate the role of renal parenchymal compression on renal function. METHODS: Two groups of swine (20-26 kg) were studied after left nephrectomy and placement of a renal artery flow probe and ureteral cannula. Two hours were allowed for equilibration, and an inulin infusion was begun to calculate inulin clearance as a measurement of glomerular filtration. In group 1 animals (n = 6), RPP was elevated by 30 mm Hg for 2 hours with renal parenchymal compression. RPP then returned to baseline for 1 hour. In group 2 (n = 6), the RPP was not elevated. The cardiac index, preload, and mean arterial pressure remained stable. Blood samples for plasma renin activity and plasma aldosterone were taken at baseline and at hourly intervals. RESULTS: Elevation of RPP in the experimental group showed no significant decrease in renal blood flow index or glomerular filtration when compared with control animals. There were no significant elevations of plasma aldosterone or plasma renin activity in the experimental animals when compared with control. CONCLUSION: Elevated renal compression alone did not create the pathophysiologic derangements seen in AACS. However, prior data from this laboratory found that renal vein compression alone caused a decreased renal blood flow and glomerular filtration and an increased plasma renin activity, plasma aldosterone, and urinary protein leak. These changes are partially or completely reversed by decreasing renal venous pressure as occurs with abdominal decompression for AACS. These data strengthen the proposal that renal vein compression, and not renal parenchymal compression, is the primary mediator of the renal derangements seen in AACS.

Abdomen↗
PubMed2000

Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: preliminary findings.

BACKGROUND: The purpose of this study was to determine the utility of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of pancreatic duct trauma and pancreas-specific complications. METHODS: Ten hemodynamically stable patients with clinically suspected pancreatic injury related to blunt abdominal trauma (n = 8), penetrating trauma (n = 1), or iatrogenic trauma (n = 1) underwent MRCP. Two abdominal radiologists conducted a review of the MRCPs to assess for the presence or absence of pancreatic duct trauma and pancreas-specific complications such as pseudocysts. The MRCP findings were correlated with endoscopic retrograde cholangiopancreatograms (n = 2), surgical findings (n = 1), computed tomographic scans (n = 10), and with clinical, biochemical or imaging follow-up (n = 10). RESULTS: Diagnostic quality MRCPs were obtained in each of the 10 patients. A mean imaging time of 5 minutes was required to perform the MRCPs. Pancreatic duct injuries were detected in four patients; pseudocysts were detected in three of these four patients. The pancreatic duct injuries in three patients were acute or subacute. In one of the three patients, disruption of a side branch of the pancreatic duct diagnosed with MRCP was not detected with endoscopic retrograde cholangiopancreatography but was confirmed surgically. In the fourth patient, the pancreatic duct injury was chronic; MRCP revealed a posttraumatic stricture in this patient who had sustained blunt abdominal trauma 17 years previously. In the remaining six patients, pancreatic duct trauma was excluded with MRCP. The information derived from the MRCPs was used to guide clinical decision-making in all 10 patients. CONCLUSIONS: MRCP enables noninvasive detection and exclusion of pancreatic duct trauma and pancreas-specific complications and provides information that may be used to guide management decisions.

Adolescent↗
PubMed2000

Pulsatile tinnitus in patients with morbid obesity: the effectiveness of weight reduction surgery.

BACKGROUND: Morbid obesity is increasing in the United States population. Morbidly obese patients may have disabling pulsatile tinnitus (PT) secondary to pseudotumor cerebri syndrome and often seek treatment from otolaryngologists because of this symptom. OBJECTIVE: To determine the effectiveness of weight reduction surgery (WRS) for relief of PT in patients with morbid obesity. STUDY DESIGN: Retrospective study of morbidly obese patients with associated PT. SETTING: Academic tertiary referral center. PATIENTS: Sixteen women with morbid obesity and associated PT who underwent WRS. RESULTS: Median age was 34 years (range 24-45 years). Average preoperative body mass index was 45 kg/m2 (range 33-70 kg/m2). Average weight loss was 45+/-17 kg (range 25-99 kg). Average postoperative weight was 75+/-14 kg (range 57-105 kg). The average preoperative cerebrospinal fluid pressure was 344+/-103 mm H2O (range 220-520 mm H2O). Postoperative measurements of cerebrospinal fluid, obtained on 4 patients, revealed an average decrease in pressure of 198 mm H2O (range 120-400 mm H2O). Thirteen patients experienced complete resolution of their PT (81%). Three patients continued to have PT despite significant weight reduction. CONCLUSIONS: Weight reduction surgery was effective in relieving PT in morbidly obese patients with associated pseudotumor cerebri syndrome and should be considered when conservative management has failed.

Adult↗
PubMed1999

Laparoscopic-assisted Roux-en-Y gastric bypass.

Eight patients underwent laparoscopic Roux-en-Y gastric bypass from May 1998 to September 1998 in which a hand-assist technique was used. The operation consisted of a 7.5-cm periumbilical midline incision along with three trocars placed in the upper abdomen. The operative times ranged from 2.25 to 4.5 h. The average preoperative body mass index was 44 kg/m2. Three-month postoperative follow-up revealed an average weight loss of 59 lb. Cosmetic results to date have been excellent even when compared with those of a total laparoscopic operation. The hand-assist technique allows the surgeon to have more control over the most difficult part of the case, which is manipulation of the small bowel in a morbidly obese abdomen.

Anastomosis, Roux-en-Y↗
PubMed1999

Gastric surgery for pseudotumor cerebri associated with severe obesity.

OBJECTIVE: To study the efficacy of gastric surgery-induced weight loss for the treatment of pseudotumor cerebri (PTC). SUMMARY BACKGROUND DATA: Pseudotumor cerebri (also called idiopathic intracranial hypertension), a known complication of severe obesity, is associated with severe headaches, pulsatile tinnitus, elevated cerebrospinal fluid (CSF) pressures, and normal brain imaging. The authors have found in previous clinical and animal studies that PTC in obese persons is probably secondary to a chronic increase in intraabdominal pressure leading to increased intrathoracic pressure. CSF-peritoneal shunts have a high failure rate, probably because they involve shunting from a high-pressure system to another high-pressure zone. In an earlier study of gastric bypass surgery in eight patients, CSF pressure decreased from 353+/-35 to 168+/-12 mm H2O at 34+/-8 months after surgery, with resolution of headaches in all. METHODS: Twenty-four severely obese women underwent bariatric surgery--23 gastric bypasses and one laparoscopic adjustable gastric banding--62+/-52 months ago for the control of severe obesity associated with PTC. CSF pressures were 324+/-83 mm H2O. Additional PTC central nervous system and cranial nerve problems included peripheral visual field loss, trigeminal neuralgia, recurrent Bell's palsy, and pulsatile tinnitus. Spontaneous CSF rhinorrhea occurred in one patient, and hemiplegia with homonymous hemianopsia developed as a complication of ventriculoperitoneal shunt placement in another. There were two occluded lumboperitoneal shunts and another functional but ineffective lumboperitoneal shunt. Additional obesity comorbidity in these patients included degenerative joint disease, gastroesophageal reflux disease, hypertension, urinary stress incontinence, sleep apnea, obesity hypoventilation, and type II diabetes mellitus. RESULTS: At 1 year after bariatric surgery, 19 patients lost an average of 45+/-12 kg, which was 71+/-18% of their excess weight. Their body mass index and percentage of ideal body weight had fallen to 30+/-5 kg/m2 and 133+/-22%, respectively. In four patients, less than 1 year had elapsed since surgery. Five patients were lost to follow-up. Surgically induced weight loss was associated with resolution of headache and pulsatile tinnitus in all but one patient within 4 months of the procedure. The cranial nerve dysfunctions resolved in all patients. The patient with CSF rhinorrhea had resolution within 4 weeks of gastric bypass. Of the 19 patients not lost to follow-up, 2 regained weight, with recurrence of headache and pulsatile tinnitus. Additional resolved associated comorbidities were 6/14 degenerative joint disease, 9/10 gastroesophageal reflux disorder, 2/6 hypertension, and all with sleep apnea, hypoventilation, type II diabetes mellitus, and urinary incontinence. CONCLUSIONS: Bariatric surgery is the long-term procedure of choice for severely obese patients with PTC and is shown to have a much higher rate of success than CSF-peritoneal shunting reported in the literature, as well as providing resolution of additional obesity comorbidity. Increased intraabdominal pressure associated with central obesity is the probable etiology of PTC, a condition that should no longer be considered idiopathic.

Adolescent↗
PubMed1999

Treatment of intracranial hypertension using nonsurgical abdominal decompression.

BACKGROUND: Elevated intra-abdominal pressure (IAP) increases intracranial pressure (ICP) and reduces cerebral perfusion pressure (CPP). We evaluated a nonsurgical means of reducing IAP to reverse this process. METHODS: Swine with a baseline ICP of 25 mm Hg produced by an intracranial balloon catheter were studied. In group 1 (n = 5), IAP was increased by 25 mm Hg. Continuous negative abdominal pressure (CNAP) was then applied. Group 2 (n = 4) had neither IAP elevation nor CNAP. Group 3 (n = 4) had CNAP without IAP elevation. RESULTS: Elevation of IAP by 25 mm Hg above baseline led to deleterious changes in ICP (25.8+/-0.8 to 39.0+/-2.8; p < 0.05) and CPP (85.2+/-2.0 to 64.8+/-2.6; p < 0.05). CNAP led to a reduction in IAP (30.2+/-1.2 to 20.4+/-1.3; p < 0.05) and improvements in cerebral perfusion (ICP, 33+/-2.7; CPP, 74.4+/-1.2; both p < 0.05). Group 2 had stable ICP (25.8+/-0.25 to 28.7+/-1.7; p > 0.05) and CPP (80.8+/-1.4 to 80.5+/-1.8; p > 0.05). In group 3, CNAP decreased cardiac index (2.9+/-0.2 to 1.1+/-0.4; p < 0.05), mean arterial pressure (105.2+/-4.0 to 38.2+/-12.0; p < 0.05), and CPP (74.2+/-4.7 to 14.5+/-12.2; p < 0.05). CONCLUSION: Elevations in IAP led to increased ICP and decreased CPP. CNAP ameliorated these intracranial disturbances. With normal IAP, CNAP impaired cerebral perfusion.

Analysis of Variance↗
PubMed1999

Effect of increased renal venous pressure on renal function.

OBJECTIVE: Acute renal failure is seen with the acute abdominal compartment syndrome (AACS). Although the cause of acute renal failure in AACS may be multifactorial, renal vein compression alone has not been investigated. This study evaluated the effects of elevated renal vein pressure (RVP) on renal function. METHODS: Two groups of swine (18-22 kg) were studied after left nephrectomy and placement of a renal artery flow probe to measure renal artery blood flow, renal vein catheter, and ureteral cannula. Two hours were allowed for equilibration and an inulin infusion was begun to calculate inulin clearance for measurement of glomerular filtration rate. Group 1 animals (n = 4) had RVP elevated by 30 mm Hg for 2 hours with renal vein constriction. RVP was then returned to baseline for 1 hour. In group 2 (n = 4), the RVP was not elevated. The cardiac index (2.9 +/- 0.5 L/min/m2) and mean arterial pressure (101 +/- 9 mm Hg) remained stable. Plasma renin activity and serum aldosterone were measured every 60 minutes. RESULTS: Elevation of RVP (0-30 mm Hg above baseline) in the experimental group showed a significant decrease in renal artery blood flow index (2.7 to 1.5 mL/min per g) and glomerular filtration rate (26 to 8 mL/min) compared with control. In addition, there was significant elevation of plasma serum aldosterone (14 to 25 microng/dL) and plasma renin activity (2.6 to 9.5 microng/mL per h) as well as urinary protein leak in the experimental animals compared with control. These changes were partially or completely reversible as RVP returned toward baseline. CONCLUSION: Elevated RVP alone leads to decreased renal artery blood flow and glomerular filtration rate and increased plasma renin activity, serum aldosterone, and urinary protein leak. These changes are consistent with the renal pathophysiology seen in AACS, morbid obesity, and preeclampsia. The changes are partially or completely reversed by decreasing renal venous pressure as occurs with abdominal decompression for AACS.

Abdomen↗
PubMed1999

Recurrent acute pancreatitis caused by a gastric duplication communicating with an aberrant pancreas.

A 24-year-old female patient who had suffered from recurrent bouts of acute pancreatitis for over 3 years was found on endoscopic retrograde cholangiopancreatography to have an aberrant pancreatic duct that terminated in a cyst. An aberrant lobe of pancreas had been discovered at exploratory laparotomy 3 years previously and was left untreated. Excision of the aberrant lobe of pancreas and accompanying gastric duplication cyst was curative. This case illustrates the importance of obtaining endoscopic retrograde cholangiopancreatography in all young individuals with recurrent pancreatitis to detect this rare, but curable, cause of pancreatitis.

Acute Disease↗
PubMed1998

Abdominal compartment syndrome.

The ACS is a clinical entity that develops from progressive, acute increases in IAP and affects multiple organ systems in a graded fashion because of differential susceptibilities. The gut is the organ most sensitive to IAH, and it develops evidence of end-organ damage before the development of the classic renal, pulmonary, and cardiovascular signs. Intracranial derangements with ACS are now well described. Treatment involves expedient decompression of the abdomen, without which the syndrome of end-organ damage and reduced oxygen delivery may lead to the development of multiple organ failure and, ultimately, death. Multiple trauma, massive hemorrhage, or protracted operation with massive volume resuscitation are the situations in which the ACS is most frequently encountered. Knowledge of the ACS, however, is also essential for the management of critically ill pediatric patients (especially those with AWD) and in understanding the limitations of laparoscopy. The role of IAH in the pathogenesis of NEC, central obesity co-morbidities, and pre-eclampsia/eclampsia remains to be fully studied.

Abdomen↗
PubMed1998

Histamine receptor antagonists, cyclooxygenase blockade, and tumor necrosis factor during acute septic insult.

Tumor necrosis factor (TNF) may be a major endogenous mediator of sepsis-induced acute organ injury. We proposed that treatment of septic pigs with the combined agents ibuprofen, a cyclooxygenase inhibitor, and histamine receptor antagonists, cimetidine (H2 antagonist) and diphenhydramine (H1 antagonist) would result in lower circulating levels of TNF and decreased parameters of sepsis-induced injury in these animals. To test this, plasma TNF activity, cardiac index, systemic and pulmonary arterial pressures, arterial PO2 and bronchoalveolar lavage protein content were monitored for 300 min in four groups of anesthetized pigs: saline-infused control pigs (n = 4); pigs infused for 60 min with Pseudomonas aeruginosa (5 x 10(8) organisms/mL, .3 mL/20 kg/min) (n = 5) and pigs infused for 60 min with P. aeruginosa plus ibuprofen (12.5 mg/kg) alone (n = 4) or ibuprofen plus cimetidine (150 mg) and diphenhydramine (30 mg/kg) at 0 and 120 min (CID, n = 4). Within 60 min, pigs infused with P. aeruginosa exhibited increased plasma TNF activity (>8-fold increase in ng/mL TNF; L929 cytolysis assay) and showed alterations in all hemodynamic and pulmonary parameters. Ibuprofen or CID administration in the septic pigs decreased peak TNF activity by 4.6 and 10.2 ng/mL, respectively, and CID treatment was correlated with better attenuation of certain sepsis-induced alterations. These results show that CID treatment attenuates sepsis-induced injury and that this is correlated with reduced plasma TNF activity in a porcine model of sepsis-induced acute organ injury.

Animals↗